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Oa Waste Tir% ey & Inspection ReA Inspection Report Number ■ <br /> CalRecycle CaaStte of Recyclel1fornia 181(Rev.10/10) 11 - 1255736 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form — Page 1 <br /> Part A-Survey _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- i / _ 3 j q _ /, I Inspection Type(Fill one) <br /> Site Suffix: LJ t / V * Routine Q Re-inspection Q Referral Q Observation <br /> Local n If Referral,choose referral type(Fill one) <br /> Identifier: U L"() Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Fru <br /> stoG`L 'a r l 3 Inspection Date <br /> Time In Time Out <br /> Business Rep Title ,1 ^^�� AM `� AM <br /> V ' <br /> I e Q PM j 1 l.� Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 7- r� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> V ® Active ® Passenger 0 Generator O Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer 0 Auto Repair p.Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> OE <br /> Inspection Form Included: Q <br /> Comments Included: i 7�f + <br /> Business Rep's Signature Phone Number Inspector's Signature Pone Number <br /> INSTRUCTIONS ON BACK Correct:40 Incorrect: IEIXIAIMIPILIEI 11 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />